Healthcare Provider Details

I. General information

NPI: 1043679053
Provider Name (Legal Business Name): JONATHAN BROOKSHIRE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC06 3870 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

MSC06 3870 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-277-3136
  • Fax: 505-277-2020
Mailing address:
  • Phone: 505-277-3136
  • Fax: 505-277-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5310
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: